NCG100004_Renewal COC Request_20181129 12:46:59 PM

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NORTH CAFOLINA
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Permit COC
NCGl00004
Number *
Enter the Certificate of Coverage (OOC) number, not the General Fbrmt nurrber (e.g., NCGO30222 is the COC, not
NOG030000) M-ST BEGIN WTTH CAPITAL "NCG'
Name of Person
Alaina Morman
Obtaining COC*
First and LastNarra
Phone Number* 9197079236
Email * [e-mail]
The COC will be e-rrailed to this contact.
Additional Email (Optional) Enter an additional email address to whom to send the CDC
Please review the information below for accuracy before submitting. If there are inconsistencies, please
contact Bethany Georgoulias at [phone] or [e-mail].
Master General NCGl00000
Permit No.
COC No.
NCG100004
Permittee
S & J Motor Co Inc Of Yadkin
Facility Name
S & J Motor Co Inc Of Yadkin
Address
4836 Old US 421 Hwy
City
Yadkinville
County
Yadkin
Waterbody
Forbush Creek
Classification
C
River Basin
Yadkin
RENEWAL STATUS
Active
Issuance Date*
10/29/2018
Effective Date
11/01/2018
1 hereby request a copy of the Certificate of Coverage (COC) entered above. I understand that the COC e-mailed as a
result of this request will serve as the Permittee's record of renewed coverage under the General Permit, and that this
record must be maintained with the Permittee's NPDES Stormwater Permit records.
Signature *
Date * 11 /29/2018